Opioids: Not an Effective Stand-Alone Treatment for Chronic Pain Following Surgery

A new study is suggesting that some common surgical procedures may be associated with an increased risk for chronic opioid use in the first year after surgery in opioid-naïve patients. Researchers looked at 11 surgical procedures and found that some patients may be at a significantly higher risk of chronic opioid use following their procedure.1

“I think going in, we suspected that patients undergoing surgery might be at higher risk for chronic opioid use.What did surprise us was the magnitude of the association, and the fact that the association was present even for patients who did not use opioids prior to the surgery and the fact that we found an association for so many procedures, even laparoscopic ones,” said study investigator Eric Sun, MD, PhD, who is an Instructor in the department of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine, Stanford, California.

He and his colleagues analyzed administrative health claims data for privately insured patients who were seen between January 1, 2001, and December 31, 2013. The analysis included 641,941 opioid-naïve surgical patients (mean age 44.0 years) and 18,011,137 opioid-naive nonsurgical patients (mean age 42.4 years). The investigators defined chronic opioid use as having filled 10 or more prescriptions or more than 120 days' supply within the first year after surgery, excluding the first 90 postoperative days.

The 11 surgical procedures included simple mastectomy, transurethral prostate resection (TURP), cataract, functional endoscopic sinus surgery (FESS), cesarean delivery, open appendectomy, laparoscopic appendectomy, open cholecystectomy, laparoscopic cholecystectomy, total hip arthroplasty (THA) and total knee arthroplasty (TKA). They found that the incidence of chronic opioid use in the first postoperative year ranged from 0.119% for cesarean delivery to 1.41% for TKA. The baseline incidence of chronic opioid use was 0.136% for nonsurgical patients.

The study showed that except for cataract surgery, laparoscopic appendectomy, FESS and TURP, all of the other surgical procedures were associated with increased risk of chronic opioid use. The highest risks were associated with TKA, open cholecystectomy, THA and simple mastectomy. The odds ratios ranged from 1.28 for cesarean delivery to 5.10 for TKA, according to the researchers.

“I think the take-home message is that even opioid-naive patients are at an increased risk for chronic opioid use after surgery. Pain specialists have an important role to play in treating these patients and in finding ways to mitigate this risk,” Dr. Sun told Clinical Pain Advisor. “I think the main message for pain specialists is to know that any of their patients who are undergoing surgery are likely to be at a higher risk for chronic opioid use after the surgery, and that they should work with other members of the care team on a perioperative plan aimed at reducing this risk.”

In the current study, patient factors associated with increased risk included being male, older than 50, and having a preoperative history of drug overuse, alcohol overuse, depression, benzodiazepine use or antidepressant use. The researchers noted that the study has significant limitations due to the fact the study sample was limited to privately insured patients ages 18 to 64, which may make the results not generalizable to other populations.

Oscar de Leon-Casasola, MD, who is Professor and Chief of the Pain Medicine Department of Anesthesiology & Pain Medicine at Roswell Park Cancer Institute, Buffalo, New York, said the study is somewhat limited because the authors did not fully address the topic of post-surgical pain syndromes. “What the authors are overlooking when making their conclusions is that the procedures associated with the higher odds ratios for postoperative opioid use in this study, also have a significant incidence of post-surgical pain syndromes. Thus, these patients invariably need pain therapy for 1 to 2 years after the surgery. For example, the literature suggest that patients undergoing TKAs have an incidence of post-surgical pain syndromes that range between 10-20%; those who underwent cesarean sections 10%,” Dr. de Leon-Casasola told Clinical Pain Advisor.

Melissa Weimer, MD, who is an Assistant Professor of Medicine, Division of Internal Medicine & Geriatrics at Oregon Health & Science University (OHSU), Portland, Oregon, said in light of the current opioid epidemic in the United States this is an important study that highlights how exposure to certain surgeries can increase patients' risk to start on the pathway of long-term opioid use.

“It is important for both patients and providers to know that how post-surgical pain is managed can potentially place patients at risk for future harms. This study also emphasizes the importance that the surgeon has an opioid cessation plan created for the patient to help him or her taper off of opioids in the post-operative setting. I frequently hear from providers that they do not know how to help patients taper off of opioids once the patient has been on them for several weeks, and patients feel that this is important information for their providers to give them,” Dr Weimer told Clinical Pain Advisor “Simply stating, ‘just stop opioids' or ‘take it slowly' is not enough instruction and can place patients at risk for harms.”

She said once a patient has developed chronic pain from a surgery, providers can be in a difficult position if patients do not have access to multimodal treatment options for their pain. “Current evidence clearly suggests that medications, particularly opioids, are not a stand-alone effective treatment for chronic pain. That said, many insurance plans do not cover alternative treatments such as complementary and alternative options, interdisciplinary pain programs, and psychological treatments for chronic pain,” said Dr. Weimer.

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